Maternal mortality may be due to one of three phenomena as stated overleaf:
Table 1 shows the contributory factors/three delays that cause maternal deaths in developing countries (Source: Ms Deborah Maine, The Safe Motherhood Action Agenda 1998:p37)8 Total contributory factors cause 7% of the deaths Poor quality of maternal health care i.e. interventions, omissions, incorrect treatment, lack of supplies, inadequate theatre facilities, insufficient skilled attendants, and poorly motivated staff cause delay 3 3 Lack of good roads, poor transportation and communication which prevents the woman’s arriving at health facilities in good time cause delay 2 2 Lack of basic education and decision making power, poverty, traditional and cultural practices which restrict women from seeking health care cause delay 1 1 CAUSES: the 3 delays NO
Table 2 illustrates the indirect causes of maternal deaths in developing countries They are responsible for 20% of the deaths. (Source: W.H.O.,1999: 14)2 Hepatitis 6 Heart disease 5 Malaria 4 Anaemia 3 Sickle Cell disease 2 HIV/AIDS 1 Causes No.
Table 3 demonstrates the direct causes of maternal deaths in developing countries (Source: SMAA,1998:2)8 73% Total obstetric causes responsibly for - Other direct causes include ectopic pregnancy, embolism, and anaesthesia – related deaths * 8% Obstructed labour and ruptured uterus 5 12% Eclampsia/Pregnancy induced hypertension 4 13% globally but in Ghana 20-30% Unsafe Abortion 3 15% Infection 2 25% Excessive bleeding 1 Percentage Causes No.
GHANA GOVERNMENT POLICY TO ENHANCE MATERNAL AND CHILD SURVIVAL
The various Governments of Ghana have put measures in place at different
times in the past. The last but one was called the National Reproductive
Health Service Protocols (M.O.H., 1999) together with the MDGs in pursuit
of the achievements of the health MDGs,4,5,&6 and the latest service protocol
known as the National Safe Motherhood service protocols are intended to
reduce maternal and infant morbidity and mortality (MOH Dec. 2008).
The strategies include:
Free maternal health services through a special health insurance scheme
The establishment of Community-based Health Planning and Services (CHPS) to carry safe motherhood services close to where women reside
The adoption of maternal health record booklet which affords continuity of care and freedom of choice of care provider.
The number of Midwives available to provide quality
maternal services is woefully inadequate, especially in
rural communities where the Midwife performs as one of
the important persons in the achievement of the MDG’s 4,5
and 6. The Programme of Action recognizes the
partnership of Private enterprises – a term called Public
Private Partnership. Midwifery education was established
in Ghana in 1928 and the Private Midwifery Practitioner has
been a very strong partner of the state in the delivery of
maternal health care. At one point there were 500, or more
of them, but now they are dwindling in number. Part of the
Agenda is to train more Midwives in order to aid in the
achievement of the MDGs 4, 5 and 6.
EFFORTS TO REDUCE MATERNAL AND INFANT MORBIDITY AND MORTALITIES IN THE PAST DECADE: THE ROLE OF THE MIDWIFE BEFORE THE YEAR 2000 MANAGEMENT OF THE THREE PHASES OF CHILDBIRTH
Phase one during pregnancy: Antenatal Care
Antenatal care is the health management and education given to the client during pregnancy. Antenatal care is an important part of preventive health care. It was initiated by Professor Ballantyne of the United Kingdom in the year 1901(Myles, 1985:173)11
The routine management according to the National Reproductive Health Service Protocols (Ghana) included a standard recommendation as follows:
Table 1 shows the recommended schedule
*Thus making a total of twelve visits. And if for any reason the standard antenatal visits are not accessible to the clients at least she should benefit from four basic visits at 10 weeks, 20 weeks, 30 weeks and 36 weeks. Yet during that period the maternal mortality rate was between 755 (KBTH) and1140 (KATH) per 100,000 live births (Larsey and Wilson, 1998) every week till birth 9 th – 12 th visits 4 every two weeks till the 36 th week 5 th – 8 th visits 3 every four weeks till 28 weeks 2 nd – 4 th visits 2 as early as 12 – 14 weeks First visit 1 Period Variable No
The goal of labour and delivery management is to promote
the most positive outcome which is, a healthy mother and
The objectives are to:
Manage the four stages of labour accurately
Make proper use of the partograph
Identify complications early and treat or refer swiftly for a positive outcome
Deliver placenta and membranes by the active management protocol (AMTSL). Keep the mother and baby (if feasible) for one hour after the delivery of the placenta in delivery room, monitor vital signs ½ hourly and observe the uterus and introitus every half an hour
* A National Maternal health record booklet for continuity of care is in practice. (MOH/GHS,R&CH UNIT, 2005)13
ROUTINE MANAGEMENT For the uncomplicated pregnancy, at least four antenatal care visits should be made as follows: Counsel the client at every visit and advise her to report to any health facility if she feels unwell. (NSMSP, 2008)12. This however has caused maternal deaths due to lack of proper decision making on the part of care providers ROUTINE LABORATORY TEST Counselling and HIV test, G6PD, Hepatitis B, CD4 count if HIV is positive and pelvic ultrasound have all been added to what used to be the case, i.e. before the year 2000. At 36 weeks Fourth visit 4 At 32 weeks Third visit 3 Between 24 and 28 weeks Second visit 2 At up to 16 weeks gestation First visit 1 PERIOD VARIABLE NO
THE ROLE OF THE MIDWIFE – ANTENTAL CARE Give Nefedipine 10mgs sublingual and refer to hospital. In hospital give 10mgs sublingual and ask Doctor to see client Check B/p, urine for proteins and oedema at every visit – vigilantly P.I.H if diastolic pressure >100mmhg 4 Give: anti-retroviral prophylaxis at 28wks if mother is HIV positive and at 30wks and counsel client on feeding options (NSMP, 2008:10) Ask for counseling and HIV testing at first visit. Do CD4 count if HIV is Positive HIV/AIDS 3 Give: paracetamol, I.V fluids of quinine 600mgs and refer to hospital. In hospital give paracetamol. Have an infusion trolley always in readiness, assist Doctor intelligently Give 3 intermittent preventive treatment (IPT) sulfadoxine 500mgs and pyremethamine 25mgs between 16 and36 weeks at 4 weeks interval Malaria 2 Provide 4 basic antenatal care: 1 st visit up to 16 weeks Antenatal care 1 Secondary Intervention Primary Intervention Variable NO
Take blood for grouping and cross matching. Give I.V fluids of N/Saline or ringers lactate 1000 mls. Give oral misoprostol 400mg stat and repeat in 4hrs if necessary or I.M injection of Ergometrine 0.2mgs. Refer to hospital Educate public/clients on dangers of unprotected sex and abortions Inevitable abortion 6 Give Nefedipine 10mgs sublingual start magnesium sulphate 4 protocol and transport client to hospital if not in second stage. If she is in labour and near delivery deliver by vacuum extraction, do other delivery interventions accurately and transfer to Hospital. In hospital – make sure I.V infusion for emergency obstetric care (EOC) is always ready – call Doctor, inform labour ward staff. Check B/p, urine for proteins and oedema at every visit – vigilantly Severe pre – eclampsia diastolic >110mmhg 5
(National Safe Motherhood Service Protocol; NSMSP 2008:21) 12 *Ask for pelvic ultrasound by 20 weeks. Also G6PD and Hepatitis B *Educate client on neonatal care immunization and danger signs *Educate on birth preparedness and complication readiness, STIS, HIV/AIDS and family planning Miscellaneous 8 Same as inevitable abortion Educate and motivate on family planning services Unsafe Abortion. In Ghana it accounts for20-30% of the deaths. 7
Promote and maintain the physical, mental and social well being of mother and baby/babies by providing education on nutrition, rest, sleep and personal hygiene
Detect and manage high risk conditions arising during labour, whether medical, surgical or obstetric
Ensure the delivery of a full term healthy baby with minimal stress or injury to mother and baby and to
Help prepare the client to breastfeed successfully, experience normal puerperium and take good care of the child physically, psychologically and socially
A safe delivery and post partum health depends on good intranatal management
Table below shows management strategy In hospital: take accurate history; examine woman physically. Make internal pelvic examination tray and I.V infusion trolley ready Call Obstetrician. Monitor client and foetus every 15 minutes and record accurately. Inform the theatre staff about a possible caesarean section. Carry out augmentation procedures intelligently. Call obstetrician in case of foetal or maternal distress immediately. Make sure resuscitation apparatuses are ready. Resuscitate baby accurately. Educate client and the significant others on the process of labour. Teach relaxation exercises. Educate client on birth preparedness and complication readiness. Screen short women with big babies and women with hip deformity for hospital delivery. Take history of labour and record observation on the partograph. If cervicograph crosses the alert line – reassure and refer to hospital without delay. Labour management – prolonged labour 1 SECONDARY PREVENTION PRIMARY PREVENTION CAUSE NO
Assess total amount blood loss through interview and observation of bed clothes and pads Check BP, pulse, temperature and assess for shock. Take blood for grouping and cross matching Give oxytocin IV 10 units IM and add 20 units to 500mls IV fluid of normal saline or ringers solution Pass urine catheter to monitor urine output Start broad – spectrum antibiotics Check uterus. Massage to stimulate contractions and also expel any blood clots. If bleeding is profuse and persists repeat oxytocin infusion Administer misoprostol rectally 800mcg Stat . Do bimananual compression of uterus Transfer to hospital In hospital do same as above. Make sure trolley for EOC is ready. Call Doctor Immediately . Continue broad spectrum antibiotics. Do not discharge before 48 hours. Check Hb at 1 st visit and at week 36 gestation. Administer iron folic acid and vitamins in pregnancy. Educate on family planning. Conduct active management of the 3 rd stage of labour. Give oxytocin 10 Units IM within one minute of delivery – after exclusion of another baby. Deliver placenta by controlled cord traction when bladder is empty. Massage uterus to maintain uterine contractions. Repeat every 15 minutes for 2 hours. Examine placenta very carefully. Inform obstetrician about missing membranes and lobes of placenta immediately. Do not discharge before 48 hrs after delivery. Because according to research findings the majority of deaths occur during the first 48 hours. Post partum haemorrhage causes 61% of maternal deaths P.P.H. 2
In hospital, assess accurately. Continue IV fluids and broad spectrum antibiotics Call Doctor for internal pelvic assessment and appropriate mode of delivery to ensure safe mother (and baby). Monitor accurately. Educate on good nutrition in childhood. Assess accurately. Make use of partograph in delivery. Transfer as fast as possible if cervicograph goes flat. Take blood for grouping and cross matching. Give IV fluids. Give antibiotics. Obstructed labour and ruptured uterus (account for 8% of the deaths) 4 In hospital, management same as in community Give broad spectrum antibiotics. Keep patient in a separate room. Continue strict infection prevention strategies especially frequent hand washing with soap and water Make use of mobile hand hygiene Unit and good decontaminants Test and manage STIs and anaemia during pregnancy. Observe strict infection prevention techniques during delivery (especially, wash hands with soap and water frequently). Make use of good decontaminants. Infection (accounts for 15% of maternal deaths) 3
If placenta has been delivered- take blood for grouping and cross matching. Give IV fluids of 500mls g/s or ringers lactate in 6 hours. Administer 10 units of oxytocin stat Give ergometrine 0.2mgs I.M or slowly I.V (NSMSP, 2007:3) Insert Foleys catheter for continues drainage. Do a bimanual compression of the uterus if bleeding still continues. Examine placenta for completeness or retention of membranes or lobes. Start broad spectrum antibiotic. Transfer to hospital. In hospital: make sure a trolley for the management of PPH is always at hand. Take blood for grouping and cross matching. Start I.V infusion of ringers lactate. Call Doctor and carry out all instructions of interventions intelligently and accurately. Organize for blood donors. Check B/P and pulse every 2 hours. Encourage client to empty bladder every 2 hours. Encourage her to breastfeed. Examine baby accurately. Report any abnormalities. Carry out routine eye instillation of antibiotics. Make both mother and baby comfortable. Organize for blood donors * 4 th stage of labour – post partum haemorrhage especially first 2 – 6hrs 5
Give broad spectrum antibiotic Give pethedine 100mgs, diazepam 10mgs I.V slowly in separate syringes. Remove placenta manually Give 20 units oxytocin in 500mls of ringers lactate at 40 – 60 dps/minute Give ergomentrine 0.2mgs I.M or misoprostol 800 – 1000mcg rectally Transfer client to hospital In hospital: Take a good history; take blood for grouping and cross matching. Start IV fluids. Call Doctor. Carry out all instructions accurately and intelligently. Advise on family planning Retained placenta – placenta not delivered within 30 minutes 6
THE CONSTRAINTS ARE MAINLY THROUGH THE THREE DELAYS
Lack of basic education and decision making power, poverty and obnoxious cultural practices and traditions which restrict women from seeking health care, cause delay 1
Lack of good roads, poor transportation and communication system which prevent the woman’s arrival at health facilities in good time, cause delay 2
Poor quality of maternal health care i.e. omissions, incorrect treatment, lack of supplies, insufficient theatre facilities, inadequate skilled attendants, and poorly motivated staff, cause delay 3
These delays have to be addressed aggressively with other collaborators e.g. Queen mothers, District Assemblies, retraining and motivation of staff, expansion of Midwifery Training Institutions, Scholarships for education up to Masters and PhD level for the supply of Lecturers in order to reduce the unacceptably high maternal and infants death rates.
EFFORTS IN REDUCING INFANT MORBIDITY AND MORTALITY
Infant mortality is the death of a child before his or
her first birth day per every 1,000 live births. Infant
mortality is often used to measure the health of a
Community or State
Globally, it was estimated to be 95 per 1,000. It is
64 per 1000 in Ghana. (NSMSP, 2008)
Infant morbidity refers to the babies that are born with
health problems and live. (Save the Children, 2010.)14
Upgrade all district hospitals for them to be able to provide complex health care specifically to include two obstetric theatres. In addition, Government is strongly requested to increase obstetric theatres to four in every regional hospital and provide up to four in all the teaching hospitals obstetric and gynaecology department, to avoid a client with impending rupture of uterus from waiting in theatre queue. (E.O.C)*
In the Little Company of Mary Hospital of Pretoria, South Africa, there are 15 theatres and in the Mayor Clinic, Rochester, U.S.A., there are over 70 theatres. So let African Governments think seriously about the need to increase the number of Obstetric theatres in order to curtail the agony of women who require theatre intervention and thereby save the lives of mothers and their babies.
4. Establish maternity waiting homes in all the resourced district health facilities for pregnant women who dwell in deprived communities to move in at 38 week gestation to wait on their deliveries. This would reduce the number of deaths which arise from delay in arriving at resourced health centres due to inaccessible road net work, lack of transportation and inadequate communication systems. (Delay two).
5. Initiate preconception health care in all health care institutions including private maternity homes in response to the government’s policy of public private partnership. This would enable the early recognition of the indirect causes of maternal death for good management and control before pregnancy takes place.
6. Revert to the 1999 schedule of Ante-natal care that made allowance for four to twelve antenatal clinic attendances. That was to ensure frequent monitoring of mother and baby especially during the third trimester when Pregnancy Induced Hypertension (P.I.H) and eclampsia are at a high prevalence rate.
Re-instate the composite partograph which makes room for the latent phase in order to identify prolonged labour in good time for swift management and positive outcome
Initiate weekly radio and television maternal and child health education programs
9. Strongly suggest the need for a bill of rights for the childbearing woman.
reduce maternal and infant mortality and morbidity.
We have only four more years to the target period
of 2015. The dateline of the MDGs achievement.
May God help us to achieve the health MDGs 4, 5 and 6 by the year 2015. Thank you for your attention.
THE PRECONCEPTION CYCLE CARE 6.Educ. on the menstrual cycle 7Educ n . Exercise and Relaxation 8. Blood tests 10. General counseling 11. Immunization 12. Environmental pollutants 13. Psychosexual counseling 14. Family Planning 15. Sub fertility HEALTHY CONCEPTION 1.Weight& height for the calculation of.BMI mass inde x Weight and height 2.Educ. on Nutrition 3. General Check ups 3a. Urine 3b. Stool 3c. Blood Pressure 3d. Breast examination and self breast examination 4. Pre-marital sex avoidance 5. Avoidance of Social poisons 9. Referral to level ‘C’ health facility/hospital for the management of the indirect causes of maternal deaths – i. Anaemia ii. Malaria iii. Sickle Cell disease iv. HIV/AIDS v. Heart Disease vi. Hepatitis